A 70 year old male with pain in the right flank

 

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CASE:

A 70 year old male with chief complaints of pain in the right flank.

HISTORY OF PRESENTING ILLNESS:

Patient was apparently asymptomatic 5 years ago.He then complained of pain during micturation,difficulty in micturation, groin pain and occassional blood in urine.

He was taken to the hospital and was diagnosed with bladder calculi which was 25mm.He was given medication.

After a year of being on medication, he came to KIMS and was diagnosed with renal stone and horse shoe kidney.

Bladder stone was surgically operated.The renal stone was not operated as it was apparently small.

Now he is complaining of pain in the flank.He also complaints of bloating after having his meals for which he takes pantop

 (2-3 tablets in a week).

DAILY ROUTINE:

He wake up at 6am 

He has his tea at 7am.

Breakfast at 10 am for which he has rice and dal

He is a farmer by occupation and has his own land.

He has lunch by 2pm for which he has rice,dal,vegetables,meat and fish.

sleeps for 1-2 hours,wakes up and watches tv while having tea

Dinner at 10pm for which he has rice,dal and vegetables 

He goes to bed at 11:00pm.

PAST HISTORY:

Not a known case of DM,Asthma,Epilepsy and Thyroid abnormalities.

Patient was diagnosed with hypertension after he came to KIMS (29/11/2022).

History of stroke 25 years ago.

PERSONAL HISTORY:

Diet: mixed

Apetite: normal

Sleep: adequate 

Bowel and bladder: regular

Addictions: h/o tobacco chewing 5 years ago and alcohol 10 years ago.

FAMILY HISTORY: None

GENERAL EXAMINATION:

Pallor: absent

Icterus: absent

Cyanosis: absent

Clubbing: clubbing of digits is present

Lymphadenopathy: absent

Pedal edema: absent

VITALS:

Temperature: 98.5 degree farenheit

Pulse: 80 beats per minute

Respiratory rate: 20 cycles per minute

Blood pressure: 140/80 mm Hg

SYSTEMIC EXAMINATION:

CVS: S1 and S2 are heard

Respiratory: bilateral vesicular breath sounds are present

CNS: no focal neurological deficits

Abdomen: soft and non tender

INVESTIGATIONS:

PROVISIONAL DIAGNOSIS:

Right renal calculus with horse shoe kidney

TREATMENT:

Tab Ultracet

Tab Amlong 10mg OD